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Current Medications (Special Needs/Disabilities (Please Complete The Attached Individualized Care Plan Form)

1) This document is a youth information form for the 2012-2013 YMCA Hendersonville Winter Break Camp program. It collects information about a child such as name, address, birthdate, medical information, emergency contacts, and expectations for the camp. 2) The form requests details about the child's allergies, medications, special needs, interests, and swimming ability. Family information is also collected including parents' names, addresses, phone numbers, and email addresses. 3) In case of an emergency, the form asks for a child's doctor and dentist contact information as well as hospital preference and insurance information. Authorized emergency pick-up contacts are also listed.

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ymcawnc
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14 views1 page

Current Medications (Special Needs/Disabilities (Please Complete The Attached Individualized Care Plan Form)

1) This document is a youth information form for the 2012-2013 YMCA Hendersonville Winter Break Camp program. It collects information about a child such as name, address, birthdate, medical information, emergency contacts, and expectations for the camp. 2) The form requests details about the child's allergies, medications, special needs, interests, and swimming ability. Family information is also collected including parents' names, addresses, phone numbers, and email addresses. 3) In case of an emergency, the form asks for a child's doctor and dentist contact information as well as hospital preference and insurance information. Authorized emergency pick-up contacts are also listed.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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2012 YMCA of WNC Hendersonville Branch

Winter Break Camp Youth Information Form


This youth information is effective for the 2012-2013 YMCA Hendersonville Winter Break Camp Program.
Childs Information
Childs name________________________________________________________________________
Address _____________________________________City ____________________ Zip ___________
___ Male ___Female

Birth date _______________Age (as of August 2012) _____ Ethnicity__________

School child attends _________________________________Grade (as of Aug. 2012) ______________


Allergies (please be specific and note level of severity, etc.):
________________________________________________________________________________
Current Medications (please note all medications AND complete the Individualized Care Plan if medications will need to be administered at
the Y program): _________________________________________________________________________________________
Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):____________________________
_____________________________________________________________________________________________________
What activities your child would enjoy while at Winter Break Camp:________________________________________________
What are your expectations for the Winter Break Program?_______________________________________________________
Names and Ages of Siblings: ______________________________________________________________________________
Swimming Ability (check one): ___ Non-Swimmer

___ Beginner

___ Intermediate

___Advanced

Family Information (List both parents/guardians AND list first the one parent/guardian (completing this form) to contact for
payments and questions.
1st Contact Parent/Guardians name _____________________________________ Employer __________________________
E-mail address ___________________________________________________________________________________
(please provide the email address that we may use for contacting you)
Home Address ______________________________________________ City _______________________ Zip _____________
Home # _________________ Work # ___________________ ext. _____ Mobile # ________________ Pager # __________
2nd Contact Parent/Guardians name _____________________________________ Employer __________________________
E-mail address ___________________________________________________________________________________
(please provide the email address that we may use for contacting you)
Home Address ______________________________________________ City _______________________ Zip _____________
Home # _________________ Work # ___________________ ext. _____ Mobile # ________________ Pager # __________

Emergency Information (If you do not have a Doctor/Dentist, please list Henderson County Health Department or another
provider of your choice. All information is REQUIRED, including hospital preference.)
In case of emergency, please contact the following first:
____Mother/Guardian ___Father/Guardian
Childs Doctor ____________________________________________ Doctors Phone # _______________________________
Childs Dentist ____________________________________________ Dentists Phone # ______________________________
Hospital Preference _____________________________________________________________________________________
Insurance Company _____________________________________________ Policy # _________________________________
Emergency Contact Information When a parent/guardian is not available, I authorize these individuals to pick-up my child:
1. Name _____________________________ Relationship to child _____________________ Home # __________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________
2. Name _____________________________ Relationship to child _____________________ Home # __________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________
3. Name _____________________________ Relationship to child _____________________ Home # __________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________

4.

Name _____________________________ Relationship to child _____________________ Home # __________________


Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________

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